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Buchanan KL, Staller K. Towards Improving Diagnosis of Dyssynergic Defecation: A Small Step or a New Paradigm? Clin Gastroenterol Hepatol 2023; 21:902-906. [PMID: 36055569 DOI: 10.1016/j.cgh.2022.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Kelly L Buchanan
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School; and, Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts.
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2
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Altered Gut Microbic Flora and Haemorrhoids: Could They Have a Possible Relationship? J Clin Med 2023; 12:jcm12062198. [PMID: 36983199 PMCID: PMC10054427 DOI: 10.3390/jcm12062198] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023] Open
Abstract
To date, the exact pathophysiology of haemorrhoids is poorly understood. The different philosophies on haemorrhoids aetiology may lead to different approaches of treatment. A pathogenic theory involving a correlation between altered anal canal microflora, local inflammation, and muscular dyssynergia is proposed through an extensive review of the literature. Since the middle of the twentieth century, three main theories exist: (1) the varicose vein theory, (2) the vascular hyperplasia theory, and (3) the concept of a sliding anal lining. These phenomena determine changes in the connective tissue (linked to inflammation), including loss of organization, muscular hypertrophy, fragmentation of the anal subepithelial muscle and the elastin component, and vascular changes, including abnormal venous dilatation and vascular thrombosis. Recent studies have reported a possible involvement of gut microbiota in gut motility alteration. Furthermore, dysbiosis seems to represent the leading cause of bowel mucosa inflammation in any intestinal district. The alteration of the gut microbioma in the anorectal district could be responsible for haemorrhoids and other anorectal disorders. A deeper knowledge of the gut microbiota in anorectal disorders lays the basis for unveiling the roles of these various gut microbiota components in anorectal disorder pathogenesis and being conductive to instructing future therapeutics. The therapeutic strategy of antibiotics, prebiotics, probiotics, and fecal microbiota transplantation will benefit the effective application of precision microbiome manipulation in anorectal disorders.
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Sadeghi A, Akbarpour E, Majidirad F, Bor S, Forootan M, Hadian MR, Adibi P. Dyssynergic Defecation: A Comprehensive Review on Diagnosis and Management. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2023; 34:182-195. [PMID: 36919830 PMCID: PMC10152153 DOI: 10.5152/tjg.2023.22148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 12/22/2022] [Indexed: 03/15/2023]
Abstract
About one-third of chronically constipated patients have an evacuation disorder, and dyssynergic defecation is a common cause of the evacuation disorder. In dyssynergic defecation, the coordination between abdominal and pelvic floor muscles during defecation is disrupted and patients cannot produce a normal bowel movement. The etiology of dyssynergic defecation is still unknown. Although a detailed history taking and a careful examination including digital rectal examination could be useful, other modalities such as anorectal manometry and balloon expulsion test are necessary for the diagnosis. Biofeedback therapy is one of the most effective and safe treatments. Here, we provide an overview of dyssynergic defecation as well as how to diagnose and manage this condition.
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Affiliation(s)
- Anahita Sadeghi
- Digestive Disease Research Institute (DDRI), Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Akbarpour
- Digestive Disease Research Institute (DDRI), Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Majidirad
- Physical Therapy Department, Tehran University of Medical Sciences Faculty of Rehabilitation Sciences, Tehran, Iran
| | - Serhat Bor
- Department of Gastroenterology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Mojgan Forootan
- Department of Gastroenterology, Gastrointestinal and Liver Diseases Research Center (RCGLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Hadian
- Department of Physical Therapy, Brain & Spinal Cord Injury Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences (TUMS) Faculty of Rehabilitation Sciences, Tehran, Iran
| | - Peyman Adibi
- Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Thorsen AJ. Management of Rectocele with and without Obstructed Defecation. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Peros G, Gingert C. Chronische Obstipation – Definition, Diagnostik und Therapie. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Knowles CH, Booth L, Brown SR, Cross S, Eldridge S, Emmett C, Grossi U, Jordan M, Lacy-Colson J, Mason J, McLaughlin J, Moss-Morris R, Norton C, Scott SM, Stevens N, Taheri S, Yiannakou Y. Non-drug therapies for the management of chronic constipation in adults: the CapaCiTY research programme including three RCTs. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background
Chronic constipation affects 1–2% of adults and significantly affects quality of life. Beyond the use of laxatives and other basic measures, there is uncertainty about management, including the value of specialist investigations, equipment-intensive therapies using biofeedback, transanal irrigation and surgery.
Objectives
(1) To determine whether or not standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback is more clinically effective than standardised specialist-led habit training alone, and whether or not outcomes of such specialist-led interventions are improved by stratification to habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or habit training alone based on prior knowledge of anorectal and colonic pathophysiology using standardised radiophysiological investigations; (2) to compare the impact of transanal irrigation initiated with low-volume and high-volume systems on patient disease-specific quality of life; and (3) to determine the clinical efficacy of laparoscopic ventral mesh rectopexy compared with controls at short-term follow-up.
Design
The Chronic Constipation Treatment Pathway (CapaCiTY) research programme was a programme of national recruitment with a standardised methodological framework (i.e. eligibility, baseline phenotyping and standardised outcomes) for three randomised trials: a parallel three-group trial, permitting two randomised comparisons (CapaCiTY trial 1), a parallel two-group trial (CapaCiTY trial 2) and a stepped-wedge (individual-level) three-group trial (CapaCiTY trial 3).
Setting
Specialist hospital centres across England, with a mix of urban and rural referral bases.
Participants
The main inclusion criteria were as follows: age 18–70 years, participant self-reported problematic constipation, symptom onset > 6 months before recruitment, symptoms meeting the American College of Gastroenterology’s constipation definition and constipation that failed treatment to a minimum basic standard. The main exclusion criteria were secondary constipation and previous experience of study interventions.
Interventions
CapaCiTY trial 1: group 1 – standardised specialist-led habit training alone (n = 68); group 2 – standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (n = 68); and group 3 – standardised radiophysiological investigations-guided treatment (n = 46) (allocation ratio 3 : 3 : 2, respectively). CapaCiTY trial 2: transanal irrigation initiated with low-volume (group 1, n = 30) or high-volume (group 2, n = 35) systems (allocation ratio 1 : 1). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy performed immediately (n = 9) and after 12 weeks’ (n = 10) and after 24 weeks’ (n = 9) waiting time (allocation ratio 1 : 1 : 1, respectively).
Main outcome measures
The main outcome measures were standardised outcomes for all three trials. The primary clinical outcome was mean change in Patient Assessment of Constipation Quality of Life score at the 6-month, 3-month or 24-week follow-up. The secondary clinical outcomes were a range of validated disease-specific and psychological scoring instrument scores. For cost-effectiveness, quality-adjusted life-year estimates were determined from individual participant-level cost data and EuroQol-5 Dimensions, five-level version, data. Participant experience was investigated through interviews and qualitative analysis.
Results
A total of 275 participants were recruited. Baseline phenotyping demonstrated high levels of symptom burden and psychological morbidity. CapaCiTY trial 1: all interventions (standardised specialist-led habit training alone, standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback and standardised radiophysiological investigations-guided habit training alone or habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback) led to similar reductions in the Patient Assessment of Constipation Quality of Life score (approximately –0.8 points), with no statistically significant difference between habit training alone and habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (–0.03 points, 95% confidence interval –0.33 to 0.27 points; p = 0.8445) or between standardised radiophysiological investigations and no standardised radiophysiological investigations (0.22 points, 95% confidence interval –0.11 to 0.55 points; p = 0.1871). Secondary outcomes reflected similar levels of benefit for all interventions. There was no evidence of greater cost-effectiveness of habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or stratification by standardised radiophysiological investigations compared with habit training alone (with the probability that habit training alone is cost-effective at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year gain; p = 0.83). Participants reported mixed experiences and similar satisfaction in all groups in the qualitative interviews. CapaCiTY trial 2: at 3 months, there was a modest reduction in the Patient Assessment of Constipation Quality of Life score, from a mean of 2.4 to 2.2 points (i.e. a reduction of 0.2 points), in the low-volume transanal irrigation group compared with a larger mean reduction of 0.6 points in the high-volume transanal irrigation group (difference –0.37 points, 95% confidence interval –0.89 to 0.15 points). The majority of participants preferred high-volume transanal irrigation, with substantial crossover to high-volume transanal irrigation during follow-up. Compared with low-volume transanal irrigation, high-volume transanal irrigation had similar costs (median difference –£8, 95% confidence interval –£240 to £221) and resulted in significantly higher quality of life (0.093 quality-adjusted life-years, 95% confidence interval 0.016 to 0.175 quality-adjusted life-years). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy resulted in a substantial short-term mean reduction in the Patient Assessment of Constipation Quality of Life score (–1.09 points, 95% confidence interval –1.76 to –0.41 points) and beneficial changes in all other outcomes; however, significant increases in cost (£5012, 95% confidence interval £4446 to £5322) resulted in only modest increases in quality of life (0.043 quality-adjusted life-years, 95% confidence interval –0.005 to 0.093 quality-adjusted life-years), with an incremental cost-effectiveness ratio of £115,512 per quality-adjusted life-year.
Conclusions
Excluding poor recruitment and underpowering of clinical effectiveness analyses, several themes emerge: (1) all interventions studied have beneficial effects on symptoms and disease-specific quality of life in the short term; (2) a simpler, cheaper approach to nurse-led behavioural interventions appears to be at least as clinically effective as and more cost-effective than more complex and invasive approaches (including prior investigation); (3) high-volume transanal irrigation is preferred by participants and has better clinical effectiveness than low-volume transanal irrigation systems; and (4) laparoscopic ventral mesh rectopexy in highly selected participants confers a very significant short-term reduction in symptoms, with low levels of harm but little effect on general quality of life.
Limitations
All three trials significantly under-recruited [CapaCiTY trial 1, n = 182 (target 394); CapaCiTY trial 2, n = 65 (target 300); and CapaCiTY trial 3, n = 28 (target 114)]. The numbers analysed were further limited by loss before primary outcome.
Trial registration
Current Controlled Trials ISRCTN11791740, ISRCTN11093872 and ISRCTN11747152.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Charles H Knowles
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Steve R Brown
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Samantha Cross
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Ugo Grossi
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mary Jordan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jon Lacy-Colson
- Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Christine Norton
- Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - S Mark Scott
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natasha Stevens
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shiva Taheri
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yan Yiannakou
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
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Srinivasan SG, Sharma M, Feuerhak K, Bailey KR, Bharucha AE. A comparison of rectoanal pressures during Valsalva maneuver and evacuation uncovers rectoanal discoordination in defecatory disorders. Neurogastroenterol Motil 2021; 33:e14126. [PMID: 33797175 PMCID: PMC8486876 DOI: 10.1111/nmo.14126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 01/31/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND It is suggested that patients with defecation disorders (DD) strain excessively or do a Valsalva maneuver (VM) during evacuation, resulting in rectoanal discoordination, which hinders rectal evacuation. However, definitive data are lacking. METHODS Rectoanal pressures during evacuation and a VM were measured with seated high-resolution manometry (HRM) in 64 healthy and 136 constipated women with a normal (84 women, C-normal) or prolonged (52 women, C-abnormal) balloon expulsion time (BET). The number of abnormal rectoanal parameters during evacuation and the joint distribution of pressures during evacuation and a VM were used to discriminate between controls and C-abnormal BET patients. KEY RESULTS The peak anal pressure (5 s) during a VM accounted for 0%, 26%, and 49% of the variance in anal pressure during evacuation in healthy women, C-normal BET, and C-abnormal BET. The association between anal pressure during a VM and evacuation was stronger in C-abnormal BET than in healthy women and C-normal BET (p for interaction <0.001). Fifty-eight of 64 controls and 33 of 52 C-abnormal BET patients had no or one abnormal parameter during evacuation; hence, the probability of C-abnormal BET was 33/91 (36%). In patients with no or one abnormal parameter during evacuation, a logistic model based on anal pressures during evacuation and a VM discriminated between controls and patients with C-abnormal BET with a sensitivity and a specificity of 67% and 75%. CONCLUSIONS Assessment of rectoanal pressures during evacuation and a VM uncovers rectaoanal discoordination and facilitates the diagnosis of DD in selected patients.
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Affiliation(s)
- Sushmitha Grama Srinivasan
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Mayank Sharma
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Kelly Feuerhak
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Kent R Bailey
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology (Drs Srinivasan and Sharma, Ms. Feuerhak, and Dr. Bharucha) and Division of Biomedical Statistics and Informatics (Dr Bailey), Mayo Clinic, Rochester, MN, USA
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9
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Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation. Neurogastroenterol Motil 2021; 33:e14050. [PMID: 33263938 DOI: 10.1111/nmo.14050] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting. PURPOSE This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.
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Affiliation(s)
- S Mark Scott
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam D Farmer
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Institute of Applied Clinical Science, University of Keele, Keele, UK
| | - Philip G Dinning
- College of Medicine and Public Health, Flinders Medical Centre, Flinders University & Discipline of Gastroenterology, Adelaide, SA, Australia
| | - Emma V Carrington
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca E Burgell
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Vic., Australia
| | - Eirini Dimidi
- Department of Nutritional Sciences, King's College London, London, UK
| | - Asma Fikree
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Gastroenterology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
| | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Caroline L Hoad
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK
| | - Charles H Knowles
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Karen Nugent
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Jose Maria Remes-Troche
- Digestive Physiology and Motility Lab, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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Chaichanavichkij P, Vollebregt PF, Scott SM, Knowles CH. Botulinum toxin type A for the treatment of dyssynergic defaecation in adults: a systematic review. Colorectal Dis 2020; 22:1832-1841. [PMID: 32403161 DOI: 10.1111/codi.15120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/18/2020] [Indexed: 02/08/2023]
Abstract
AIM Dyssynergic defaecation (DD) is characterized by inappropriate coordination of the pelvic floor muscles during defaecation, resulting in impaired stool expulsion. The mainstay of treatment is biofeedback and alternative therapies are limited in those who do not respond. This systematic review evaluated botulinum toxin type A injection (BTXA) as a treatment option for dyssynergia. METHODS PubMed, Embase and Cochrane Central Register of Controlled Trials were searched for studies evaluating adult patients with DD treated with BTXA injection into the puborectalis and/or external anal sphincter. All study designs, except case reports, were included in the review with no language restriction. Studies limited to patients with specific neurological diagnoses or with a follow-up period under 1 month were excluded. Study selection, assessment and data extraction were performed by two reviewers and results were synthesized narratively. RESULTS Eleven studies (three randomized control trials) involving 248 participants were included. All studies used the transanal approach to deliver the injection, most commonly at the 3 and 9 o'clock positions using digital palpation for guidance. The most commonly used patient position was left lateral, and most studies did not use any anaesthesia. The dose of BTXA varied (Botox 12-100 units, Dysport 100-500 units), and outcomes measured were heterogeneous (global rating ± up to five investigations). Symptomatic improvement varied between 29.2% and 100% and adverse effects occurred in 0% to 70%. CONCLUSION The evidence to support using BTXA for DD is poor and only covers a transanal approach. Future studies should redress these limitations: heterogeneity of design, dose and outcome measures.
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Affiliation(s)
- P Chaichanavichkij
- National Bowel Research Centre and GI Physiology Unit (Colorectal Services), Centre of Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - P F Vollebregt
- National Bowel Research Centre and GI Physiology Unit (Colorectal Services), Centre of Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - S M Scott
- National Bowel Research Centre and GI Physiology Unit (Colorectal Services), Centre of Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - C H Knowles
- National Bowel Research Centre and GI Physiology Unit (Colorectal Services), Centre of Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, London, UK
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Jain M, Singh S, Baijal R. Diagnostic value of the balloon expulsion test compared with anorectal manometry in Indian patients with dyssynergic defecation. PRZEGLAD GASTROENTEROLOGICZNY 2020; 15:151-155. [PMID: 32550948 PMCID: PMC7294974 DOI: 10.5114/pg.2020.95558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/31/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Digital rectal examination (DRE) and balloon expulsion test (BET) are simple tests to diagnose dyssynergic defecation (DD). AIM To determine differences in symptoms and manometry findings in patients with abnormal BET and normal BET. The secondary objective was to ascertain the sensitivity and specificity of BET and DRE + BET for the diagnosis of DD in an Indian setting using ARM findings as the gold standard. MATERIAL AND METHODS Retrospective analysis of patients with chronic constipation referred for anorectal manometry (ARM) between December 2012 and March 2019. DD was diagnosed using ARM. Findings on BET and, in a subset of cases, on DRE + BET were compared with ARM findings. The data were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Agreement of BET and DRE + BET with ARM was calculated using Cohen's κ coefficient. A p-value of < 0.05 was considered significant. RESULTS A total of 1006 cases (734 males, 73%) formed the study cohort. Patients with abnormal BET more frequently reported digitation, bleeding per rectum, and straining (p < 0.00001). Moreover, they had a significantly higher median basal pressure compared to those with normal BET (80 vs. 67, p = 0.03). DD was significantly more common in those with abnormal BET. The sensitivity, specificity, PPV, and NPV of BET in detecting DD were 28.29%, 97.15%, 81.13%, and 75.78%, respectively. The percentage of agreement was 76.34%, and there was fair degree of correlation between the two tests. In a smaller subset of cases (166), DRE and BET findings were both available for analysis. We noted that the sensitivity, specificity, PPV, and NPV of combined DRE + BET were 57.63%, 88.79%, 73.91%, and 79.17%, respectively. The Cohen's κ correlation coefficient was 0.49, suggesting moderate agreement. CONCLUSIONS Patients with abnormal BET more frequently report digitation, straining, and bleeding per rectum, and have higher resting anal pressure. BET is a good screening test for DD in an Indian setting.
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Affiliation(s)
- Mayank Jain
- Department of Gastroenterology, Arihant Hospital and Research Centre, Indore, India
| | - Saransh Singh
- Department of Gastroenterology, Pushpavati Singhania Hospital and Research Centre, New Delhi, India
| | - Rajiv Baijal
- Department of Gastroenterology, Pushpavati Singhania Hospital and Research Centre, New Delhi, India
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12
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Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology 2020; 158:1232-1249.e3. [PMID: 31945360 PMCID: PMC7573977 DOI: 10.1053/j.gastro.2019.12.034] [Citation(s) in RCA: 293] [Impact Index Per Article: 58.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Abstract
With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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Grossi U, Di Tanna GL, Heinrich H, Taylor SA, Knowles CH, Scott SM. Systematic review with meta-analysis: defecography should be a first-line diagnostic modality in patients with refractory constipation. Aliment Pharmacol Ther 2018; 48:1186-1201. [PMID: 30417419 DOI: 10.1111/apt.15039] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/16/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Defecography is considered the reference standard for the assessment of pelvic floor anatomy and function in patients with a refractory evacuation disorder. However, the overlap of radiologically significant findings seen in patients with chronic constipation (CC) and healthy volunteers is poorly defined. AIM To systematically review rates of structural and functional abnormalities diagnosed by barium defecography and/or magnetic resonance imaging defecography (MRID) in patients with symptoms of CC and in healthy volunteers. METHODS Electronic searches of major databases were performed without date restrictions. RESULTS From a total of 1760 records identified, 175 full-text articles were assessed for eligibility. 63 studies were included providing data on outcomes of 7519 barium defecographies and 668 MRIDs in patients with CC, and 225 barium defecographies and 50 MRIDs in healthy volunteers. Pathological high-grade (Oxford III and IV) intussuscepta and large (>4 cm) rectoceles were diagnosed in 23.7% (95% CI: 16.8-31.4) and 15.9% (10.4-22.2) of patients, respectively. Enterocele and perineal descent were observed in 16.8% (12.7-21.4) and 44.4% (36.2-52.7) of patients, respectively. Barium defecography detected more intussuscepta than MRID (OR: 1.52 [1.12-2.14]; P = 0.009]). Normative data for both barium defecography and MRID structural and functional parameters were limited, particularly for MRID (only one eligible study). CONCLUSIONS Pathological structural abnormalities, as well as functional abnormalities, are common in patients with chronic constipation. Since structural abnormalities cannot be evaluated using nonimaging test modalities (balloon expulsion and anorectal manometry), defecography should be considered the first-line diagnostic test if resources allow.
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Affiliation(s)
- Ugo Grossi
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Luca Di Tanna
- Department of Econometrics, Statistics and Applied Economics, Riskcenter - IREA, Universitat de Barcelona, Barcelona, Spain
| | - Henriette Heinrich
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Charles H Knowles
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Mark Scott
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Spoelstra SK, Weijmar Schultz WCM, Reissing ED, Borg C, Broens PM. The distinct impact of voluntary and autonomic pelvic floor muscles on genito-pelvic pain/penetration disorder. SEXUAL AND RELATIONSHIP THERAPY 2018. [DOI: 10.1080/14681994.2018.1442568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Symen K. Spoelstra
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Willibrord C. M. Weijmar Schultz
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Elke D. Reissing
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Charmaine Borg
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands
| | - Paul M.A. Broens
- Department of Surgery, Anorectal Physiology Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Grossi U, Stevens N, McAlees E, Lacy-Colson J, Brown S, Dixon A, Di Tanna GL, Scott SM, Norton C, Marlin N, Mason J, Knowles CH. Stepped-wedge randomised trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation: study protocol for a randomized controlled trial. Trials 2018; 19:90. [PMID: 29402303 PMCID: PMC5800022 DOI: 10.1186/s13063-018-2456-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/30/2017] [Indexed: 02/08/2023] Open
Abstract
Background Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence. Methods An individual level, stepped-wedge randomised trial has been designed to allow observer-blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) pre-operative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates. Discussion An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks). Trial registration ISRCTN registry, ISRCTN11747152. Registered on 30 September 2015. The trial was prospectively registered (first patient enrolled on 21 March 2016). Electronic supplementary material The online version of this article (10.1186/s13063-018-2456-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ugo Grossi
- National Bowel Research Cente (NBRC) - Digestive Disease, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Natasha Stevens
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary, University of London, London, UK
| | - Eleanor McAlees
- National Bowel Research Cente (NBRC) - Digestive Disease, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, 4 Newark Street, London, E1 2AT, UK
| | | | | | | | - Gian Luca Di Tanna
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary, University of London, London, UK
| | - S Mark Scott
- National Bowel Research Cente (NBRC) - Digestive Disease, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, 4 Newark Street, London, E1 2AT, UK
| | | | - Nadine Marlin
- Pragmatic Clinical Trials Unit, Blizard Institute, Queen Mary, University of London, London, UK
| | | | - Charles H Knowles
- National Bowel Research Cente (NBRC) - Digestive Disease, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, 4 Newark Street, London, E1 2AT, UK
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Camilleri M, Ford AC, Mawe GM, Dinning PG, Rao SS, Chey WD, Simrén M, Lembo A, Young-Fadok TM, Chang L. Chronic constipation. Nat Rev Dis Primers 2017; 3:17095. [PMID: 29239347 DOI: 10.1038/nrdp.2017.95] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Charlton Bldg., Rm. 8-110, Rochester, Minnesota 55905, USA
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds and Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Gary M Mawe
- Department of Neurological Sciences, The University of Vermont, Burlington, Vermont, USA
| | - Phil G Dinning
- Departments of Gastroenterology & Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Satish S Rao
- Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Magnus Simrén
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anthony Lembo
- Digestive Disease Center, Beth Israel Deaconess Hospital, Boston, Massachusetts, USA
| | | | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Skardoon GR, Khera AJ, Emmanuel AV, Burgell RE. Review article: dyssynergic defaecation and biofeedback therapy in the pathophysiology and management of functional constipation. Aliment Pharmacol Ther 2017; 46:410-423. [PMID: 28660663 DOI: 10.1111/apt.14174] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/18/2016] [Accepted: 05/13/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Functional constipation is a common clinical presentation in primary care. Functional defaecation disorders are defined as the paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defaecation (dyssynergic defaecation) and/or inadequate propulsive forces during attempted defaecation. Prompt diagnosis and management of dyssynergic defaecation is hindered by uncertainty regarding nomenclature, diagnostic criteria, pathophysiology and efficacy of management options such as biofeedback therapy. AIM To review the evidence pertaining to the pathophysiology of functional defaecation disorders and the efficacy of biofeedback therapy in the management of patients with dyssynergic defaecation and functional constipation. METHODS Relevant articles addressing functional defaecation disorders and the efficacy of biofeedback therapy in the management of dyssynergic defaecation and functional constipation were identified from a search of Pubmed, MEDLINE Ovid and the Cochrane Library. RESULTS The prevalence of dyssynergic defaecation in patients investigated for chronic constipation is as many as 40%. Randomised controlled trials have demonstrated major symptom improvement in 70%-80% of patients undergoing biofeedback therapy for chronic constipation resistant to standard medical therapy and have determined it to be superior to polyethylene glycol laxatives, diazepam or sham therapy. Long-term studies have shown 55%-82% of patients maintain symptom improvement. CONCLUSIONS Dyssynergic defaecation is a common clinical condition in patients with chronic constipation not responding to conservative management. Biofeedback therapy appears to be a safe, successful treatment with sustained results for patients with dyssynergic defaecation. Further studies are required to standardise the diagnosis of dyssynergic defaecation in addition to employing systematic protocols for biofeedback therapy.
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Affiliation(s)
| | - A J Khera
- Alfred Health Continence Clinic, Caulfield, Vic., Australia
| | - A V Emmanuel
- GI Physiology Unit, University College Hospital, National Hospital for Neurology and Neurosurgery, London, UK
| | - R E Burgell
- Alfred Health and Monash University, Melbourne, Vic., Australia
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Gastrointestinal manifestations of pelvic floor disorders in adolescents: a diagnostic framework for the general practitioner. Curr Opin Pediatr 2017; 29:420-425. [PMID: 28537946 DOI: 10.1097/mop.0000000000000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Pelvic floor disorders (PFDs) can present with gastrointestinal complaints in the adolescent patient, and identification of PFDs is aided by clues in the history and physical examination apparent to the knowledgeable clinician. The aim of this article is to provide a framework for the diagnostic evaluation of the adolescent patient with a PFD and introduce management strategies. RECENT FINDINGS Patients with PFDs can present with gastrointestinal symptoms, including abdominal pain, constipation, incomplete evacuation, and fecal incontinence or nongastrointestinal complaints around genitourinary symptoms or sexual health. Although such symptoms can be attributed to a variety of diagnoses, PFDs should be considered in the adolescent patient based on history and physical examination findings, including a careful digital rectal examination. Adolescent patients in high-risk groups may be especially susceptible to PFDs. Such groups include postpartum women, victims of sexual abuse, those with congenital anorectal malformations, or acquired spinal cord or pelvic floor injuries. Biofeedback can be beneficial in patients with PFDs. SUMMARY PFDs may present with a spectrum of symptoms, but a familiarity with the clinical characteristics and understanding of the digital rectal examination may guide the skillful clinician in diagnosis, initial management, and subspecialist referral if needed.
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Emmett C, Close H, Mason J, Taheri S, Stevens N, Eldridge S, Norton C, Knowles C, Yiannakou Y. Low-volume versus high-volume initiated trans-anal irrigation therapy in adults with chronic constipation: study protocol for a randomised controlled trial. Trials 2017; 18:151. [PMID: 28359279 PMCID: PMC5374566 DOI: 10.1186/s13063-017-1882-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 03/08/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Constipation is common in adults and up to 20% of the population report this symptom. Chronic constipation (CC), usually defined as more than 6 months of symptoms, is less common but results in 0.5 million UK GP consultations per annum. The effect of symptoms on measured quality of life (QOL) is significant, and CC consumes significant health care resources. In the UK, it is estimated that 10% of district nursing time is spent on constipation. Trans-anal irrigation therapy has become a widely used treatment despite a lack of robust efficacy data to support its use. The long-term outcome of treatment is also unclear. A randomised comparison of two different methods of irrigation (high- and low-volume) will provide valuable evidence of superiority of one system over the other, as well as providing efficacy data for the treatment as a whole. METHODS Participants will be recruited based on predetermined eligibility criteria. Following informed consent, they will be randomised to either high-volume (HV) or low-volume (LV) irrigation and undergo standardised radiological and physiological investigations. Following training, they will commence home irrigation with the allocated device. Data will be collected at 1, 3, 6 and 12 months according to a standardised outcomes framework. The primary outcome is PAC-QOL, measured at 3 months. The study is powered to detect a 10% difference in outcome between systems at 3 months; this means that 300 patients will need to be recruited. DISCUSSION This study will be the first randomised comparison of two different methods of trans-anal irrigation. It will also be the largest prospective study of CC patients treated with irrigation. It will provide evidence for the effectiveness of irrigation in the treatment of CC, as well as the comparative effectiveness of the two methods. This will enable more cost-effective and evidence-based use of irrigation. Also, the results will be combined with the other studies in the CapaCiTY programme to generate an evidence-based treatment algorithm for CC in adults. TRIAL REGISTRATION ISRCTN, identifier: ISRCTN11093872 . Registered on 11 November 2015. Trial not retrospectively registered. Protocol version 3 (22 January 2016).
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Affiliation(s)
| | - Helen Close
- School of Medicine, Pharmacy and Health, Durham University Queen’s Campus, University Boulevard, Thornaby, Stockton-on-Tees, TS17 6BH UK
| | - James Mason
- WMS – Population Evidence and Technologies, University of Warwick, Coventry, CV4 7AL UK
| | - Shiva Taheri
- Blizard Institute, Queen Mary University of London, 1st Floor Abernethy Building, 2 Newark St, London, E1 2AT UK
| | - Natasha Stevens
- Blizard Institute, Queen Mary University of London, 1st Floor Abernethy Building, 2 Newark St, London, E1 2AT UK
| | - Sandra Eldridge
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58 Turner St., London, E1 2AB UK
| | - Christine Norton
- Kings College London, 2.25 James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA UK
| | - Charles Knowles
- Blizard Institute, Queen Mary University of London, 1st Floor Abernethy Building, 2 Newark St, London, E1 2AT UK
| | - Yan Yiannakou
- University Hospital of North Durham, North Road, Durham, DH1 5TW UK
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Norton C, Emmanuel A, Stevens N, Scott SM, Grossi U, Bannister S, Eldridge S, Mason JM, Knowles CH. Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: study protocol for a randomised controlled trial. Trials 2017; 18:139. [PMID: 28340625 PMCID: PMC5366116 DOI: 10.1186/s13063-017-1880-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 03/08/2017] [Indexed: 02/08/2023] Open
Abstract
Background Constipation affects up to 20% of adults. Chronic constipation (CC) affects 1–2% of adults. Patient dissatisfaction is high; nearly 80% feel that laxative therapy is unsatisfactory and symptoms have significant impact on quality of life. There is uncertainty about the value of specialist investigations and whether equipment-intensive therapies using biofeedback confer additional benefit when compared with specialist conservative advice. Methods/design A three-arm, parallel-group, multicentre randomised controlled trial. Objectives: to determine whether standardised specialist-led habit training plus pelvic floor retraining using computerised biofeedback is more clinically effective than standardised specialist-led habit training alone; to determine whether outcomes are improved by stratification based on prior investigation of anorectal and colonic pathophysiology. Primary outcome measure is response to treatment, defined as a 0.4-point (10% of scale) or greater reduction in Patient Assessment of Constipation–Quality of Life (PAC-QOL) score 6 months after the end of treatment. Other outcomes up to 12 months include symptoms, quality of life, health economics, psychological health and qualitative experience. Hypotheses: (1) habit training (HT) with computer-assisted direct visual biofeedback (HTBF) results in an average reduction in PAC-QOL score of 0.4 points at 6 months compared to HT alone in unselected adults with CC, (2) stratification to either HT or HTBF informed by pathophysiological investigation (INVEST) results in an average 0.4-point reduction in PAC-QOL score at 6 months compared with treatment not directed by investigations (No-INVEST). Inclusion: chronic constipation in adults (aged 18–70 years) defined by self-reported symptom duration of more than 6 months; failure of previous laxatives or prokinetics and diet and lifestyle modifications. Consenting participants (n = 394) will be randomised to one of three arms in an allocation ratio of 3:3:2: [1] habit training, [2] habit training and biofeedback or [3] investigation-led allocation to one of these arms. Analysis will be on an intention-to-treat basis. Discussion This trial has the potential to answer some of the major outstanding questions in the management of chronic constipation, including whether costly invasive tests are warranted and whether computer-assisted direct visual biofeedback confers additional benefit to well-managed specialist advice alone. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN11791740. Registered on 16 July 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1880-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Anton Emmanuel
- University College Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - Natasha Stevens
- Blizard Institute, Queen Mary University of London, 2 Newark Street, London, E1 2AT, UK
| | - S Mark Scott
- Blizard Institute, Queen Mary University of London, 2 Newark Street, London, E1 2AT, UK
| | - Ugo Grossi
- Blizard Institute, Queen Mary University of London, 2 Newark Street, London, E1 2AT, UK
| | - Sybil Bannister
- Blizard Institute, Queen Mary University of London, 2 Newark Street, London, E1 2AT, UK
| | - Sandra Eldridge
- Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - James M Mason
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Charles H Knowles
- Blizard Institute, Queen Mary University of London, 2 Newark Street, London, E1 2AT, UK
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Bouchoucha M, Devroede G, Bon C, Bejou B, Mary F, Benamouzig R. Is-it possible to distinguish irritable bowel syndrome with constipation from functional constipation? Tech Coloproctol 2017; 21:125-132. [PMID: 28066860 DOI: 10.1007/s10151-016-1580-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 12/07/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Rome III criteria classify patients complaining of constipation into two main groups: patients with functional constipation (FC) and patients with constipation predominant irritable bowel syndrome (IBS-C). The purpose of this study was to identify differences in the intensity of symptoms and total and segmental colonic transit time in these two types of patients. METHODS We performed a prospective evaluation of 337 outpatients consecutively referred for chronic constipation and classified according to the Rome III criteria as FC or IBS-C. They were asked to report symptom intensity, on a 10-point Likert scale, for diarrhea, constipation, bloating and abdominal pain. Stool form was reported using the Bristol scale, and colonic transit time was measured by using multiple-ingestion single-marker single-film technique. Statistical analysis was completed by a discriminant analysis. RESULTS Female gender and obstructed defecation was more frequent in IBS-C patients than in FC patients. IBS-C patients reported greater symptom intensity than FC patients, but stool form, and total and segmental colonic transit time were not different between the two groups. Multivariate logistic regression showed that only two parameters, bloating and abdominal pain, were related to the IBS-C or to the FC phenotype, and discriminant analysis showed that these two parameters were sufficient to give a correct classification of 71% of the patients. CONCLUSIONS Our study suggests that self-evaluation of abdominal pain and bloating is more helpful than colonic transit time in classifying patient as IBS-C or FC.
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Affiliation(s)
- M Bouchoucha
- Department of Physiology, Paris Descartes University, Paris, France.
- Gastroenterology Department, Avicenne Hospital Bobigny, 93009, Bobigny Cedex, France.
| | - G Devroede
- Department of Surgery, Sherbrooke University Medical School, Sherbrooke, Canada
| | - C Bon
- Gastroenterology Department, Avicenne Hospital Bobigny, 93009, Bobigny Cedex, France
| | - B Bejou
- Gastroenterology Department, Avicenne Hospital Bobigny, 93009, Bobigny Cedex, France
| | - F Mary
- Gastroenterology Department, Avicenne Hospital Bobigny, 93009, Bobigny Cedex, France
| | - R Benamouzig
- Gastroenterology Department, Avicenne Hospital Bobigny, 93009, Bobigny Cedex, France
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Pisano U, Irvine L, Szczachor J, Jawad A, MacLeod A, Lim M. Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus. Ann Coloproctol 2016; 32:170-174. [PMID: 27847787 PMCID: PMC5108663 DOI: 10.3393/ac.2016.32.5.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 09/22/2016] [Indexed: 02/07/2023] Open
Abstract
Purpose Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus. Methods Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of <0.05 was significant. Results Forty-three patients (42 female patients) underwent anorectal physiology and radiology imaging. The median age was 54 years (interquartile range, 41.5–60 years). Anismus was seen radiologically and physiologically in 18 (41.8%) and 12 patients (27.9%), respectively. The agreement between modalities was 0.298 (P = 0.04). Using physiology as a reference, radiology had positive and negative predictive values of 44% and 84%, respectively. Rectoceles, cystoceles, enteroceles and pathological pelvic floor descent were not physiologically predictive of animus (P > 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08). Conclusion Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.
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Affiliation(s)
- Umberto Pisano
- Department of General Sugery, Raigmore Hospital, Inverness, United Kingdom.; Department of Clinical and Interventional Radiology, Royal Victoria Hospital, Belfast, United Kingdom
| | - Lesley Irvine
- Department of Clinical Physiology, Raigmore Hospital, Inverness, United Kingdom
| | - Justina Szczachor
- Department of General Surgery, Raigmore Hospital, Inverness, United Kingdom
| | - Ahsin Jawad
- Department of General Surgery, Raigmore Hospital, Inverness, United Kingdom
| | - Andrew MacLeod
- Department of Radiology, Raigmore Hospital, Inverness, United Kingdom
| | - Michael Lim
- Department of General Surgery, Raigmore Hospital, Inverness, United Kingdom
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Kairaluoma M, Raivio P, Kupila J, Aarnio M, Kellokumpu I. The Role of Biofeedback Therapy in Functional Proctologic Disorders. Scand J Surg 2016; 93:184-90. [PMID: 15544072 DOI: 10.1177/145749690409300303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Aims: The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation. Material and Methods: Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database. Results: Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes. Conclusions: Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.
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Affiliation(s)
- M Kairaluoma
- Department of Gastroenterological Surgery Jyväskylä Central Hospital, Jyväskylä, Finland.
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Caetano AC, Santa-Cruz A, Rolanda C. Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests? Can J Gastroenterol Hepatol 2016; 2016:8654314. [PMID: 27847802 PMCID: PMC5101368 DOI: 10.1155/2016/8654314] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/22/2016] [Indexed: 01/29/2023] Open
Abstract
Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and time-consuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests of DD. Methods. We performed a systematic search in PUBMED and MEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (I2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to perform better when a cut-off time of 2 minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD.
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Affiliation(s)
- Ana C. Caetano
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - André Santa-Cruz
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
- Department of Internal Medicine, Braga Hospital, Braga, Portugal
| | - Carla Rolanda
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
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Emile SH, Elfeki HA, Elbanna HG, Youssef M, Thabet W, Abd El-Hamed TM, Said B, Lotfy A. Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review. World J Gastrointest Pharmacol Ther 2016; 7:453-462. [PMID: 27602248 PMCID: PMC4986396 DOI: 10.4292/wjgpt.v7.i3.453] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/20/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of botulinum toxin type A (BTX-A) in the management of patients with anismus.
METHODS: An organized search of published literature was conducted using electronic databases including: PubMed/MEDLINE, and Cochrane Central Register of Controlled Trials, also an internet-based search using “Google Scholar” service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and long-term clinical improvement, post-injection changes in electromyography (EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection.
RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU (range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonography-guided technique, one study used EMG-guided technique, whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4% (range 37.5%-86.7%), this percentage declined to a median of 46% (range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between (37.5%-80%), (54%-86.7%), and (25%-86.6%), respectively. Fourteen (7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%.
CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.
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Rao SSC, Patcharatrakul T. Diagnosis and Treatment of Dyssynergic Defecation. J Neurogastroenterol Motil 2016; 22:423-35. [PMID: 27270989 PMCID: PMC4930297 DOI: 10.5056/jnm16060] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 04/27/2016] [Indexed: 12/11/2022] Open
Abstract
Dyssynergic defecation is common and affects up to one half of patients with chronic constipation. This acquired behavioral problem is due to the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. A detailed history, prospective stool diaries, and a careful digital rectal examination will not only identify the nature of bowel dysfunction, but also raise the index of suspicion for this evacuation disorder. Anorectal physiology tests and balloon expulsion test are essential for a diagnosis. Newer techniques such as high-resolution manometry and magnetic resonance defecography can provide mechanistic insights. Recently, randomized controlled trials have shown that biofeedback therapy is more effective than laxatives and other modalities, both in the short term and long term, without side effects. Also, symptom improvements correlated with changes in underlying pathophysiology. Biofeedback therapy has been recommended as the first-line of treatment for dyssynergic defecation. Here, we provide an overview of the burden of illness and pathophysiology of dyssynergic defecation, and how to diagnose and treat this condition with biofeedback therapy.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
| | - Tanisa Patcharatrakul
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA.,Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Grossi U, Carrington EV, Bharucha AE, Horrocks EJ, Scott SM, Knowles CH. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut 2016; 65:447-55. [PMID: 25765461 PMCID: PMC4686376 DOI: 10.1136/gutjnl-2014-308835] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/18/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The diagnostic accuracy of anorectal manometry (AM), which is necessary to diagnose functional defecatory disorders (FDD), is unknown. Using blinded analysis and standardised reporting of diagnostic accuracy, we evaluated whether AM could discriminate between asymptomatic controls and patients with functional constipation (FC). DESIGN Derived line plots of anorectal pressure profiles during simulated defecation were independently analysed in random order by three expert observers blinded to health status in 85 women with FC and 85 age-matched asymptomatic healthy volunteers (HV). Using accepted criteria, these pressure profiles were characterised as normal (ie, increased rectal pressure coordinated with anal relaxation) or types I-IV dyssynergia. Interobserver agreement and diagnostic accuracy were determined. RESULTS Blinded consensus-based assessment disclosed a normal pattern in 16/170 (9%) of all participants and only 11/85 (13%) HV. The combined frequency of dyssynergic patterns (I-IV) was very similar in FC (80/85 (94%)) and HV (74/85 (87%)). Type I dyssynergia ('paradoxical' contraction) was less prevalent in FC (17/85 (20%) than in HV (31/85 (36.5%), p=0.03). After statistical correction, only type IV dyssynergia was moderately useful for discriminating between FC (39/85 (46%)) and HV (17/85 (20%)) (p=0.001, positive predictive value=70.0%, positive likelihood ratio=2.3). Interobserver agreement was substantial or moderate for identifying a normal pattern, dyssynergia types I and IV, and FDD, and fair for types II and III. CONCLUSIONS While the interpretation of AM patterns is reproducible, nearly 90% of HV have a pattern that is currently regarded as 'abnormal' by AM. Hence, AM is of limited utility for distinguishing between FC and HV.
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Affiliation(s)
- Ugo Grossi
- National Centre for Bowel Research and Surgical Innovation and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Emma V Carrington
- National Centre for Bowel Research and Surgical Innovation and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Emma J Horrocks
- National Centre for Bowel Research and Surgical Innovation and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - S Mark Scott
- National Centre for Bowel Research and Surgical Innovation and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Charles H Knowles
- National Centre for Bowel Research and Surgical Innovation and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
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Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options. Eur J Gastroenterol Hepatol 2015; 27:204-14. [PMID: 25629565 DOI: 10.1097/meg.0000000000000288] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic constipation is a considerable problem because it significantly affects the quality of a patient's life. Constipation can be diagnosed at every age and is more frequent in women and among the elderly. In epidemiological studies, its incidence is estimated at 2-27% in the general population. Chronic constipation may be primary or secondary. However, primary constipation (functional or idiopathic) can be classified into normal transit constipation, slow transit constipation, and pelvic outlet obstruction. In this review we make an attempt to present the current pathophysiological aspects and new therapeutic options for chronic idiopathic constipation, particularly highlighting the value of patient assessment for accurate diagnosis of the cause of the problem, thus helping in the choice of appropriate treatment.
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30
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Zhang Y, Wang ZN, He L, Gao G, Zhai Q, Yin ZT, Zeng XD. Botulinum toxin type-A injection to treat patients with intractable anismus unresponsive to simple biofeedback training. World J Gastroenterol 2014; 20:12602-12607. [PMID: 25253964 PMCID: PMC4168097 DOI: 10.3748/wjg.v20.i35.12602] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 04/30/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of botulinum toxin type A injection to the puborectalis and external sphincter muscle in the treatment of patients with anismus unresponsive to simple biofeedback training.
METHODS: This retrospective study included 31 patients suffering from anismus who were unresponsive to simple biofeedback training. Diagnosis was made by anorectal manometry, balloon expulsion test, surface electromyography of the pelvic floor muscle, and defecography. Patients were given botulinum toxin type A (BTX-A) injection and pelvic floor biofeedback training. Follow-up was conducted before the paper was written. Improvement was evaluated using the chronic constipation scoring system.
RESULTS: BTX-A injection combined with pelvic floor biofeedback training achieved success in 24 patients, with 23 maintaining persistent satisfaction during a mean period of 8.4 mo.
CONCLUSION: BTX-A injection combined with pelvic floor biofeedback training seems to be successful for intractable anismus.
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31
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ba-bai-ke-re MMTJA, Wen NR, Hu YL, Zhao L, Tuxun T, Husaiyin A, Sailai Y, Abulimiti A, Wang YH, Yang P. Biofeedback-guided pelvic floor exercise therapy for obstructive defecation: An effective alternative. World J Gastroenterol 2014; 20:9162-9169. [PMID: 25083090 PMCID: PMC4112871 DOI: 10.3748/wjg.v20.i27.9162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 02/26/2014] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare biofeedback-guided pelvic floor exercise therapy (BFT) with the use of oral polyethylene glycol (PEG) for the treatment of obstructive defecation.
METHODS: A total of 88 subjects were assigned to treatment with either BFT (n = 44) or oral PEG (n = 44). Constipation symptoms (including difficult evacuation, hard stool, digitation necessity, incomplete emptying sensation, laxative dependence, perianal pain at defecation, and constipation satisfaction), Wexner Scores, and quality of life scores were assessed after 1, 3, and 6 mo.
RESULTS: At the 6 mo follow-up, the symptoms of the BFT group patients showed significantly greater improvements compared with the PEG group regarding difficult evacuation, hard stools, digitation necessity, laxative dependence, perianal pain at defecation, constipation satisfaction, Wexner Constipation Score, and quality of life score (P < 0.05). The quality of life score of the BFT group at the final follow-up time (6 mo) was 80 ± 2.2. After a complete course of training, improvements in the clinical symptoms of the BFT group were markedly improved (P < 0.05), and the Wexner Constipation Scores were greatly decreased compared with the oral PEG group (P < 0.05).
CONCLUSION: We concluded that manometric biofeedback-guided pelvic floor exercise training is superior to oral polyethylene glycol therapy for obstructive defecation.
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Abstract
BACKGROUND Sacral neuromodulation (SN) is an emerging treatment for constipation. This review evaluates the mechanism of action, techniques, efficacy, and adverse effects of SN in the management of constipation. METHODS Electronic searches for studies describing the use of SN were performed in PubMed, MEDLINE and Embase. Abstracts were reviewed and full text copies of all relevant articles obtained. RESULTS Fifty-nine results were obtained on the initial searches. Ten studies discussed the results of SN in patients with constipation. A total of 225 temporary neuromodulations and 125 permanent implants were performed. Bowel diaries showed improvement in assessment criteria in more than 50% of patients on temporary neuromodulation and the results were maintained in approximately 90% of patients who underwent permanent implantation over medium to long-term follow-up. The rate of adverse effects was high, but the majority of them were related to electrode position. Improvements in transit studies and anorectal physiology after neuromodulation were noted in some studies. The recognized limitations included a lack of randomized studies and an inability to perform meta-analysis. CONCLUSION Sacral neuromodulation may be an effective treatment in selected patients with constipation and should be a part of the management repertoire. Improvement in defecatory frequency with temporary wire placement is a good predictor of subsequent response following permanent implant. Further research into predictive factors for success would improve patient selection.
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Affiliation(s)
- A Sharma
- 1Leeds Teaching Hospitals, Leeds, UK
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33
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Basilisco G, Coletta M. Chronic constipation: a critical review. Dig Liver Dis 2013; 45:886-93. [PMID: 23639342 DOI: 10.1016/j.dld.2013.03.016] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/04/2013] [Accepted: 03/18/2013] [Indexed: 12/11/2022]
Abstract
Chronic constipation is a very common symptom that is rarely associated with life-threatening diseases, but has a substantial impact on patient quality of life and consumption of healthcare resources. Despite the large number of affected patients and the social relevance of the condition, no cost-effectiveness analysis has been made of any diagnostic or therapeutic algorithm, and there are few data comparing different diagnostic and therapeutic approaches in the long term. In this scenario, increasing emphasis has been placed on demonstrating that a number of older and new therapeutic options are effective in treating chronic constipation in well-performed randomised controlled trials, but there is still debate as to when these therapeutic options should be included in diagnostic and therapeutic algorithms. The aim of this review is to perform a critical evaluation of the current diagnostic and therapeutic options available for adult patients with chronic constipation in order to identify a rational patient approach; furthermore we attempt to clarify some of the more controversial points to aid clinicians in managing this symptom in a more efficacious and cost-effective manner.
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Affiliation(s)
- Guido Basilisco
- Gastroenterology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore, Policlinico, Milan, Italy.
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Zhang T, Chon TY, Liu B, Do A, Li G, Bauer B, Wang L, Liu Z. Efficacy of acupuncture for chronic constipation: a systematic review. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2013; 41:717-42. [PMID: 23895148 DOI: 10.1142/s0192415x13500493] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This study was to evaluate the efficacy and safety of acupuncture for chronic functional constipation. Randomized controlled trials were searched in several databases. The primary outcome was a change in the number of weekly spontaneous bowel movements. The secondary outcomes included colonic transit activity, effective rate, Cleveland Clinic Score, and health-related quality of life score. Meta-analysis was done by using RevMan 5.1. After strict screening, 15 RCTs were included, containing 1256 participants. All of them were conducted in China and published in Chinese journals. Meta-analysis indicated that acupuncture for chronic functional constipation was probably as effective as conventional medical therapy in the change of bowel movements. For the colonic transit activity, acupuncture might be the same as conventional medical therapy and could be better than sham acupuncture. For the Cleveland Clinic Score, acupuncture was unlikely inferior to conventional medical therapy and the deep acupuncture was better than normal depth acupuncture in abdominal region. No obvious adverse event was associated with acupuncture for constipation. In conclusion, acupuncture for chronic functional constipation is safe and may improve weekly spontaneous bowel movements, quality of life, and relevant symptoms. However, the evidence was limited by the small sample size and the methodological quality.
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Affiliation(s)
- Tao Zhang
- Guang An Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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35
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Botulinum toxin for conditions of the female pelvis. Int Urogynecol J 2013; 24:1073-81. [DOI: 10.1007/s00192-012-2035-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 12/20/2012] [Indexed: 11/26/2022]
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BHARUCHA ADILE, PEMBERTON JOHNH, LOCKE GRICHARD. American Gastroenterological Association technical review on constipation. Gastroenterology 2013; 144:218-38. [PMID: 23261065 PMCID: PMC3531555 DOI: 10.1053/j.gastro.2012.10.028] [Citation(s) in RCA: 540] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- ADIL E. BHARUCHA
- Division of Gastroenterology and Hepatology Mayo Clinic and Mayo Medical School Rochester, Minnesota
| | - JOHN H. PEMBERTON
- Division of Colon and Rectal Surgery Mayo Clinic and Mayo Medical School Rochester, Minnesota
| | - G. RICHARD LOCKE
- Division of Gastroenterology and Hepatology Mayo Clinic and Mayo Medical School Rochester, Minnesota
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Abstract
Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve an optimal outcome. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. As the pelvis contains many structures, a pelvic support or function defect frequently affects other pelvic organs. Optimal outcomes can only be achieved by selecting appropriate treatment modalities that address all of the components of a patient's problem.
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Affiliation(s)
- C. Neal Ellis
- Division of Colorectal Surgery, West Penn Allegheny Health System, Pittsburgh, Pennsylvania.
| | - Rahila Essani
- Division of Colorectal Surgery, West Penn Allegheny Health System, Pittsburgh, Pennsylvania.
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Bassotti G, Villanacci V, Bellomi A, Fante R, Cadei M, Vicenzi L, Tonelli F, Nesi G, Asteria CR. An assessment of enteric nervous system and estroprogestinic receptors in obstructed defecation associated with rectal intussusception. Neurogastroenterol Motil 2012; 24:e155-61. [PMID: 22188470 DOI: 10.1111/j.1365-2982.2011.01850.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The pathophysiological basis of obstructed defecation (OD) is still incompletely understood. In particular, few or no data are available concerning the enteric nervous system (ENS) in this condition. We investigated ENS abnormalities in patients with OD, undergoing surgery, together with the presence of estrogen (α and β) and progesterone receptors, and compare the results with those obtained in controls. METHODS Full-thickness rectal samples were obtained from 17 patients undergoing stapled transanal rectal resection for OD associated with rectal intussusception. Samples were analyzed by immunohistochemistry for enteric neurons, enteric glial cells, interstitial cells of Cajal (ICC), and for estrogen and progesterone receptors. Data were compared with those obtained in 10 controls. KEY RESULTS No differences between patients and controls were found for enteric neurons, whereas (compared with controls) OD patients displayed a significant decrease of enteric glial cells in both the submucous (P = 0.0006) and the myenteric (P < 0.0001) plexus. ICC were significantly increased in patients in the submucosal surface (P < 0.0001) and the myenteric area (P < 0.0001). Concerning estroprogestinic receptors, both were present on ICC in patients and controls. Estrogen receptors α and progesterone receptors were absent on enteric neurons and enteric glial cells in patients and controls, whereas estrogen receptors β were present in all controls and in 69% of patients' enteric neurons (P = 0.18) and in 12% of patients' glial cells (P = 0.0001). CONCLUSIONS & INFERENCES Patients with OD associated to rectal intussusception display abnormalities of the ENS and of estrogen receptors β.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy.
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Hompes R, Harmston C, Wijffels N, Jones OM, Cunningham C, Lindsey I. Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus ('pseudoanismus') is excluded. Colorectal Dis 2012; 14:224-30. [PMID: 21689279 DOI: 10.1111/j.1463-1318.2011.02561.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus. METHOD Botulinum toxin was administered, under local anaesthetic, into the puborectalis/external sphincter of patients with proctographic anismus. Responders (resolution followed by recurrence of obstructed defecation over a 1- to 2-month period) underwent repeat injection. Nonresponders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5. RESULTS Fifty-six patients were treated with botulinum toxin. Twenty-two (39%) responded initially and 21/22 (95%) underwent repeat treatment. At a median follow up of 19.2 (range, 7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated obstructed defecation symptoms (OR = 7.8, P = 0.008), but not proctographic or physiological factors, predicted response on logistic regression analysis. In 33 (97%) of 34 nonresponders, significant abnormalities were demonstrated at EUA: 31 (94%) had a grade 3-5 rectal prolapse, one had internal anal sphincter myopathy and one had a fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%. CONCLUSION Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.
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Affiliation(s)
- R Hompes
- Oxford Pelvic Floor Centre, Department of Colorectal Surgery, Churchill Hospital, Oxford, UK
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Murad-Regadas SM, Regadas FSP, Barreto RGL, Rodrigues LV, Fernandes GODS, Lima DMDR. Is dynamic two-dimensional anal ultrasonography useful in the assessment of anismus? A comparison with manometry. ARQUIVOS DE GASTROENTEROLOGIA 2011; 47:368-72. [PMID: 21225147 DOI: 10.1590/s0004-28032010000400009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 05/12/2010] [Indexed: 01/18/2023]
Abstract
CONTEXT Anismus is a prevalent functional cause of outlet delay. It is characterized by symptoms of obstructed defecation associated with paradoxical contraction of the pelvic floor muscles. OBJECTIVE To evaluate the ability of two dimensional anal ultrasonography to identify anismus patients with paradoxical contraction or normal relaxation, comparing findings with manometric measurements. METHODS Forty-nine women presenting with outlet delay and a mean validated Wexner constipation score of 13.5 were included in a prospective study. Following screening with anal manometry, the patients were assigned to one of two groups: G-I -with normal relaxation and G-II -patients with anismus. Dynamic anorectal ultrasonography was used to quantifier the movement of the puborectalis muscle and to measure changes in the angle between two converging lines drawn from the 3 o'clock and the 9 o'clock positions of the endoprobe circumference to the internal border of the puborectalis muscle. The angle decreases during straining in patients with normal relaxation, but increases in patients with anismus. The agreement between the two techniques was verified with the Kappa index. RESULTS In manometry, during straining the anal canal pressure decreased by 41.3% in G-I and increased by 168.6% in G-II, indicating a diagnosis of anismus for the second group. In US, during straining, the angle produced by the movement of the puborectalis muscle decreased from 63 ± 1.31 to 58 ± 1.509 degrees (P = 0.0135) in 23 of the 30 patients in G-I, indicating normal relaxation, and increased from 66 ± 0.972 to 72 ± 0.897 degrees (P = 0.0001) in 16 of the 19 patients in G-II, indicating anismus. The index of agreement between manometry and two dimensional anal ultrasonography was moderate: 77% (23/30) for G-I and 84% (16/19) for G-II. CONCLUSION Two-dimensional dynamic anal ultrasonography showed similar results previously suggested by anal manometry at identifying patients with normal relaxation or paradoxical contraction.
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Zuchelli T, Myers SE. Gastrointestinal issues in the older female patient. Gastroenterol Clin North Am 2011; 40:449-66, x. [PMID: 21601791 DOI: 10.1016/j.gtc.2011.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
As the body ages, it undergoes a multitude of changes. Some of these changes are visible, whereas others are not and may be elicited during the patient encounter. Some gastrointestinal issues may be more common in the elderly population and possibly in older women. These issues range from motility disorders, such as fecal incontinence and constipation, to changes in neuropeptide function and its effect on the anorexia of aging. This article comprehensively reviews gastrointestinal issues that commonly afflict the elderly female population.
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Affiliation(s)
- Tobias Zuchelli
- Drexel University College of Medicine, 245 North 15th Street, 5th Floor New College Building, Philadelphia, PA 19107, USA.
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Benetti TH, Santos MF, Mergulhão MEA, Fagundes JJ, Ayrizono MDLS, Coy CSR. Variation of the anal resting pressure induced by postexpiratory apnea effort in patients with constipation. ARQUIVOS DE GASTROENTEROLOGIA 2011; 48:30-5. [PMID: 21537539 DOI: 10.1590/s0004-28032011000100007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 10/15/2010] [Indexed: 11/21/2022]
Abstract
CONTEXT Intestinal constipation--a common symptom among the general population--is more frequent in women. It may be secondary to an improper diet or organic or functional disturbances, such as dyskinesia of the pelvic floor. This is basically characterized by the absence of relaxation or paradoxical contraction of the pelvic floor and anal sphincter during evacuation. OBJECTIVE To analyze, by manometric data, the anal pressure variation at rest, during evacuation effort by using the Valsalva maneuver and forced post-expiratory apnea in subjects with secondary constipation. METHODS Twenty-one patients (19 females--90.4%) with a mean age of 47.5 years old (23-72) were studied. The diagnosis was performed using anorectal manometry, with a catheter containing eight channels disposed at the axial axis, measuring the proximal (1) and distal (2) portions of the anal orifice. The elevation of the pressure values in relation to the resting with the evacuation effort was present in all patients. The Agachan score was used for clinical evaluation of constipation. The variables studied were: mean anal pressure of the anal orifice for 20 seconds at rest, the effort of evacuation using Valsalva maneuver and the effort of evacuation during apnea after forced expiration, as well as the area under the curve of the manometric tracing at moments Valsalva and apnea. RESULTS The analysis of the mean values of the anal pressure variation at rest evidenced difference between proximal and distal channels (P = 0.007), independent of the moment and tendency to differ during moments Valsalva and apnea (P = 0.06). The mean of values of the area under the manometric tracing curve showed differences between moments Valsalva and apnea (P = 0.0008), either at the proximal portion or at the distal portion of the anal orifice. CONCLUSION The effort of evacuation associated with postexpiratory apnea, when compared with the effort associated with the Valsalva maneuver, provides lower elevation of anal pressure at rest by the parameter area under the curve.
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Affiliation(s)
- Thaís Helena Benetti
- Department of Surgery, Faculty of Medical Sciences, University of Campinas FCM, UNICAMP.
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Savitt L, Thurler A. Biofeedback for Constipation and Fecal Incontinence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2010.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Reiner CS, Tutuian R, Solopova AE, Pohl D, Marincek B, Weishaupt D. MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value. Br J Radiol 2011; 84:136-44. [PMID: 21257836 DOI: 10.1259/bjr/28989463] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES We describe the spectrum of findings and the diagnostic value of MR defecography in patients referred with suspicion of dyssynergic defecation. METHODS 48 patients (34 females, 14 males; mean age 48 years) with constipation and clinically suspected dyssynergic defecation underwent MR defecography. Patients were divided into patients with dyssynergic defecation (n = 18) and constipated patients without dyssynergic defecation (control group, n = 30). MRIs were analysed for evacuation ability, time to initiate evacuation, time of evacuation, changes in the anorectal angle (ARA-change), presence of paradoxical sphincter contraction and presence of additional pelvic floor abnormalities. Sensitivity, specificity, positive and negative predictive values and accuracy for the diagnosis of dyssynergic defecation were calculated. RESULTS The most frequent finding was impaired evacuation, which was seen in 100% of patients with dyssynergic defecation and in 83% of the control group, yielding a sensitivity for MR defecography for the diagnosis of dyssynergic defecation of 100% (95% confidence interval (CI) 97-100%), but a specificity of only 23% (95% CI 7-40%). A lower sensitivity (50%; 95% CI 24-76%) and a high specificity (97%; 95% CI 89-100%) were seen with abnormal ARA-change. The sensitivity of paradoxical sphincter contraction was relatively high (83%; 95% CI 63-100%). A combined analysis of abnormal ARA-change and paradoxical sphincter contraction allowed for the detection of 94% (95% CI 81-100%) of the patients with dyssynergic defecation. CONCLUSION MR defecography detects functional and structural abnormal findings in patients with clinically suspected dyssynergic defecation. Impaired evacuation is seen in patients with functional constipation owing to other pelvic floor abnormalities than dyssynergic defecation.
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Affiliation(s)
- C S Reiner
- Institute of Diagnostic Radiology, University Hospital Zürich, Switzerland.
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Pelvic floor dyssynergia: efficacy of biofeedback training. Arab J Gastroenterol 2011; 12:15-9. [PMID: 21429449 DOI: 10.1016/j.ajg.2011.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 10/05/2010] [Accepted: 10/30/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND STUDY AIMS Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia (anismus). It is a behavioural disorder (no associated morphological or neurological abnormalities); consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback. PATIENTS AND METHODS Sixty patients (35 females and 25 males) with a mean age of 30±12years and a 4year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions (colon-transit time, anorectal manometry, EMG and defaecography) were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of (6±2) sessions. RESULTS At the end of sessions, 55 out of 60 patients (91.6%) reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patient's satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions. CONCLUSION Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia.
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Bassotti G, Villanacci V. Can "functional" constipation be considered as a form of enteric neuro-gliopathy? Glia 2010; 59:345-50. [PMID: 21264943 DOI: 10.1002/glia.21115] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 11/03/2010] [Indexed: 12/12/2022]
Abstract
Constipation has been traditionally viewed and classified as a functional or idiopathic disorder. However, evidence has been accumulating that suggests how constipation might be considered as due to abnormalities of the enteric nervous system, since alterations of this system, not evident in conventional histological examination, may be present in these patients. These abnormalities often consist in decrease or loss of the enteric glial cells, a pathological finding present in most types of constipation so far investigated. In this article we will discuss these evidences, and will try to consider constipation no more as a simple functional or idiopathic disorder but as a form of enteric neuro-gliopathy.
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Affiliation(s)
- Gabrio Bassotti
- Department of Clinical and Experimental Medicine, Gastroenterology and Hepatology Section, University of Perugia, Italy.
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Tantiphlachiva K, Rao P, Attaluri A, Rao SSC. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol 2010; 8:955-60. [PMID: 20656061 DOI: 10.1016/j.cgh.2010.06.031] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 06/29/2010] [Accepted: 06/30/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Dyssynergic defecation is a common cause of chronic constipation; its diagnosis requires anorectal physiological tests that are not widely available. It is not known whether digital rectal examination (DRE) can be used to identify dyssynergia. We examined the diagnostic yield of DRE in patients with dyssynergic defecation. METHODS Consecutive patients with chronic constipation (Rome III criteria, n = 209) underwent DREs, anorectal manometry analyses, balloon expulsion tests, and colonic transit studies. In the DRE, dyssynergia was identified by 2 or more of the following features: impaired perineal descent, paradoxic anal contraction, or impaired push effort; diagnostic yields were compared with physiological test results. RESULTS Of the patients included in the study, 187 (87%) had dyssynergic defecation, based on standard criteria; 134 (73%) of these were identified to have features of dyssynergia, based on DREs. The sensitivity and specificity of DRE for identifying dyssynergia in patients with chronic constipation were 75% and 87%, respectively; the positive predictive value was 97%. DRE was able to identify normal resting and normal squeeze pressure in 86% and 82% of dyssynergic patients, respectively. CONCLUSIONS DRE appears to be a reliable tool for identifying dyssynergia in patients with chronic constipation and detecting normal, but not abnormal, sphincter tone. DREs could facilitate the selection of appropriate patients for further physiologic testing and treatment.
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Affiliation(s)
- Kasaya Tantiphlachiva
- Division of Gastroenterology and Hepatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Comparative study between surgical and non-surgical treatment of anismus in patients with symptoms of obstructed defecation: a prospective randomized study. J Gastrointest Surg 2010; 14:1235-43. [PMID: 20499203 DOI: 10.1007/s11605-010-1229-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 05/11/2010] [Indexed: 02/07/2023]
Abstract
PURPOSE This study came to compare the results of biofeedback retraining biofeedback (BFB), botulinum toxin botulinum type A (BTX-A) injection and partial division of puborectalis (PDPR) in the treatment of anismus patients. PATIENTS AND METHODS Consecutive patients treated for anismus fulfilled Rome II criteria for functional constipation at our institution were evaluated for inclusion. Participants were randomly allocated to receive BFB, BTX-A injection, and PDPR. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography activity of the anal sphincter. Follow up was conducted weekly in the first month then monthly for about 1 year. Study variables included clinical improvement, patient satisfaction, and objective improvement. RESULTS Sixty patients with anismus were randomized and completed the study. The groups differed significantly regarding clinical improvement at 1 month (50% for BFB, 75%BTX-A injection, and 95% for PDPR, P = 0.006) and differences persisted at 1 year (30% for BFB, 35%BTX-A injection, and 70% for PDPR, P = 0.02). Constipation score of the patients significantly improved postPDPR and BTX-A injection. Manometric relaxation was achieved significantly in the three groups. CONCLUSION Biofeedback retraining has a limited therapeutic effect, BTX-A injection seems to be successful for temporary treatment but PDPR is found to be an effective with lower morbidity in contrast to its higher success rate in treating anismus.
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Shin JK, Cheon JH, Kim ES, Yoon JY, Lee JH, Jeon SM, Bok HJ, Park JJ, Moon CM, Hong SP, Lee YC, Kim WH. Predictive capability of anorectal physiologic tests for unfavorable outcomes following biofeedback therapy in dyssynergic defecation. J Korean Med Sci 2010; 25:1060-5. [PMID: 20592899 PMCID: PMC2890884 DOI: 10.3346/jkms.2010.25.7.1060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Accepted: 12/30/2009] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population.
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Affiliation(s)
- Jae Kook Shin
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Sook Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Yoon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Ha Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soung Min Jeon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jung Bok
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Functional anorectal disorders include solitary rectal ulcer syndrome, rectocele, nonrelaxing puborectalis syndrome, and descending perineal syndrome. Patients usually present with "constipation," but the clinical picture of these disorders includes rectal pain and bleeding, digitalization, incomplete evacuation, and a feeling of obstruction. Diagnosis is difficult because many findings can be seen in normal patients as well. The diagnosis is made by using a combination of clinical picture, defecography, pathology, and occasionally anometry and pudendal terminal motor nerve latency. These disorders are generally treated medically with dietary changes and biofeedback. Surgical intervention is reserved for patients with intractable symptoms and has not been universally successful.
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Affiliation(s)
- Melissa L Times
- Division of Colon & Rectal Surgery, Henry Ford Hospital, Detroit, MI 48202, USA
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